Within the field of neurology, there has been limited discussion of how to best respect patient autonomy in patients presenting with an acute stroke, who often have impairments in language and cognition. In addition to performing a detailed neurologic examination and providing a thorough timeline of their current presentation and medical history, these patients and their families are then asked to quickly make critical medical decisions regarding acute stroke therapies (thrombolysis and endovascular therapy). These discussions are often limited by time constraints and inadequate opportunities for patient education regarding acute stroke care. This article discusses some of the challenges of preserving patient autonomy in patients presenting with acute stroke and the advent of a stroke advance directive (Coordinating Options for Acute Stroke Therapy [COAST]) aimed to overcome these obstacles.